Unclaimed policy baggage in the Bush plan
AEIdeas
Just about every presidential campaign’s policy plans leave a lot of blanks and rhetorical placeholders, to be filled in later. They also straddle conflicting pressure points and dodge inevitable tradeoffs. The preference is to point in a general, and seemingly more popular, direction, without offering too many instructions for how to traverse the complicated path from here to there. On top of that, the limited attention spans of most voters, let alone candidates, cannot be taxed too much (unlike their incomes).
Bold “new” proposals mostly are limited to the shopworn inventory of existing ones that have not yet succeeded, though we still hope that the next time is different.
So, judged in that context and grading on the political curve, the recent Bush proposal doesn’t do too badly on the policy vision front. However, it doesn’t take much effort to find some items it touches gingerly, conflicts it fuzzes over, or future problems it does not fully anticipate.
Republican presidential candidate Jeb Bush speaks at a business roundtable in Portsmouth, New Hampshire May 20, 2015. REUTERS/Brian Snyder.
Most notably, the Bush plan reinvests heavily in delegating the thorniest Obamacare repeal-and-replace issues to state officials. Whether it involves crafting new insurance protections for individuals with costly pre-existing health conditions, transition arrangements for current enrollees in the Affordable Care Act’s exchanges and expanded Medicaid programs, regulating health insurance with a more market-friendly touch, or overhauling inefficient and overstretched state Medicaid programs, the Bush plan mostly proposes to loosen the federal thumbscrews and assume that state governments will do better.
On the one hand, fifty different mistakes (and a few better guesses) in health policy can’t possibly do as much harm as decades of Washington-based national health policy have produced. But the political incentives driving state officeholders are not markedly different from those driving national policymakers. They just lack larger (monopoly) market share and a less-restricted credit card. All state politicians may not quite be mice just studying to become rats, but they do share similar strands of DNA with their federal counterparts.
The next stage of Bush plan development should involve a little more elaboration on just how accountability by states to produce better outcomes, with greater discretion, would operate. Are future funds more subject to risk versus reward incentives? Some illustrations of what effective state innovations and alternative policy pathways have already demonstrated, or are willing to be placed at two-sided risk, would be more persuasive. And not just Florida examples — where transparency initiatives set higher marks than the mixed record of experimentation with choice of Medicaid benefits, behavioral incentives, and premium assistance for employer-based coverage.
A far bolder vision would sketch out how creative state and local agencies might break down their current silos of programmatic “assistance” to vulnerable individuals to involve them better as partners in addressing their current and future health needs more effectively. “Consumer-driven” care needs to put more initial choice and control in actual consumers and patients, rather than stopping with handoffs to another set of government intermediaries. However, the pragmatic side of the Bush plan is tempered by the tension between turning individuals loose even more to make some mistakes on their own and relying on other political intermediaries to do that for them!
(See also: protecting employer-sponsored insurance against sudden disruption versus empowering individuals to determine their own insurance coverage arrangements.)
Instead of explicitly targeting a priority list of regulations to overturn or dramatically reshape, the Bush plan proposes to establish an independent commission to conduct a regulatory spring-cleaning. How novel! Keep some space open on the bookshelf for its eagerly anticipated future report.
Left undiscussed in the Bush plan is how it will maneuver past the budget scoring barriers of the Congressional Budget Office, as well as the standard political optics test of: “So just how are you going to guarantee that your plan will cover as many people as Obamacare, etc.?”
Note the recent House Republican reconciliation bill language aiming to repeal Obamacare’s auto-enrollment of workers in larger employer health plans – albeit based more on complaints by employers than by their employees. The next iteration of the Bush plan might struggle to advance automatic enrollment of millions of other uninsured Americans into so-called low-cost default insurance plans whose premiums match the amount of refundable tax credits for non-employer-group insurance — even if it does help CBO coverage and cost scoring look better, on paper.
Finally, there’s a reform plan for Medicare. Actually, there isn’t one … yet. It’s still going to be one of the questions on the final exam.
